Endoscopic retrograde cholangiopancreatography

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Overview

Endoscopic retrograde cholangiopancreatography (ERCP) is a technique that combines the use of endoscopy and fluoroscopy to diagnose and treat certain biliary or pancreatic ductal diseases. ERCP was first introduced in 1968 and was later on accepted as a safe diagnostic and therapeutic tool [1]. Nowadays, as other imaging techniques are evolving and becoming widely used for the diagnosis of diseases of the biliary and pancreatic systems, the use of ERCP became mainly targeted towards therapeutic rather than diagnostic purposes.

Procedure

ERCP is a technique that combines video endoscopy and fluoroscopy. It is usually done in an outpatient setting and the patient is often sedated or anaesthetized. A flexible side viewing camera (endoscope) is inserted through the mouth, down the esophagus, into the stomach, through the pylorus into the duodenum. The ampulla of Vater, which is the opening of the common bile duct and pancreatic duct, is identified. This region can be directly visualized with the endoscopic camera while various procedures are performed.

Once the ampulla is identified, a plastic catheter or cannula is inserted through the ampulla, and radiocontrast material is injected into the bile ducts, and/or, pancreatic duct. Fluoroscopy, which uses X-rays, is used to locate strictures, blockages, or leakage of bile into the peritoneum as well as to guide therapeutic procedures.

A wire and balloon may be passed into the bile duct, then inflated in order to expand the opening of the bile duct to allow passage of gallstones. When needed, the opening of the ampulla can be enlarged with an electrified wire (sphincterotome) and access into the bile duct obtained so that gallstones may be removed or other therapy performed.

Other procedures associated with ERCP include the trawling of the common bile duct with a basket or balloon to remove gallstones and the insertion of a plastic stent to assist the drainage of bile. Also, the pancreatic duct can be cannulated and stents be inserted.

Incidence

Risk factors

In alphabetical order

Acute cholangitis

Anticoagulation use within 72 hours

Coagulopathy

Papillary Stenosis

Sphincterectomy

The most important risk factor for post-ERCP hemorrhage is sphincterectomy .
The length of incision as well as the use of antiplatelets and NSAIDS do not increase the risk of bleeding following ERCP.[3]

Prevention

Antibiotic prophylaxis covering gram negative bacteria and enterococci should be considered before an ERCP in patients with known or suspected biliary obstruction in which there is a risk of incomplete drainage by ERCP. This is usually the case of patients with primary sclerosing cholangitis.[3]